Creating an Accurate-and Early-View of Patient Financial Status [Healthcare Financial Management]

(Healthcare Financial Management Via Acquire Media NewsEdge) Patients are increasingly paying out of pocket for some or all of their health care because of rising copayments and deductibles or lack of access to healthcare coverage. Hospitals are discovering that communicating with patients about their financial responsibility before providing health care is an important strategy for receiving prompt and full payments while also creating a positive patient experience. This HFMA Executive Roundtable focuses on effective ways that hospitals can proactively identify and communicate about patient financial status.

When does your staff obtain financial information from scheduled patients Stacy Calvaruso: We have a combined scheduling and preregistration process in which we ask for patient financial information at the time the service is scheduled. We verify insurance and benefits electronically while the patient is on the phone. If a patient is coming in for a well visit or a simple procedure, the scheduler shares payment expectations, such as the amount of a copayment, and informs the patient that payment is required at check-in. If a patient is scheduled for a more complicated service, such as any type of surgery, the patient's file is given to our preservice center, where staff complete a full case review. Staff then use our estimation tool to calculate the patient's out-of-pocket expense for that specific case, as well as any outstanding debt with the organization. After determining the patient's financial responsibility, preservice staff call the patient to discuss what his or her insurance covers, how much the patient owes, and how the patient would like to pay for the service.

If a patient does not have insurance benefits and the service is medically necessary, we have an algorithm for calculating a minimum deposit amount. This formula is predetermined by specialty and service, so everyone receiving a specific type of care who does not have insurance would pay a similar deposit amount. The scheduler or preservice center staff would discuss the minimum deposit amount with the patient and communicate that payment is expected at check-in. If the patient expresses concern about paying the deposit, we first attempt to establish a payment plan that meets the patient's needs as well as ours. If that is not possible, we inform the patient about financial assistance options, including charity care. Patients who need further financial assistance are referred to our financial counselors.

Sue Ojeda: We preregister our scheduled patients over the phone between five and 10 days before they arrive. During the call, we gather both demographic and financial information. We also have a real-time eligibility verification system that verifies insurance and benefits for most of our payers while the patient is on the phone. If there are any problems, staff can address them with the patient immediately. For uninsured patients, we screen their ability to pay and determine whether they need financial assistance. This could include a sliding fee, a loan, a federal or state assistance program, or charity care.

María Persons: We also have a patient estimator that looks at an individual's insurance plan, eligibility information, and scheduled procedure and gives information on patient payment responsibility. We share this estimate with the patient on the phone. We are also starting to send a written copy of the estimate to our outpatients. Our goal is to provide all patients with a written estimate in the future.

Joseph Koons: We use a two-pronged effort that starts with scheduling and continues with preregistration. When a provider or patient calls to schedule a procedure, we collect the basic financial information, which lays the groundwork for future financial discussions. We then conduct medical necessity checking and eligibility verification. Automated insurance verification is integrated with our enterprise scheduling solution, so it is easy to perform this function in real time.

At the point of preregistration, we talk with the patient about financial expectations. We provide a written financial estimate that is developed through our price estimator tool, which is connected to both our claims and contract management systems. Our staff members have access to patient credit information so they can anticipate a patient's need for financial assistance before preregistration. If the patient expresses concern about financial difficulties, staff move the conversation toward financial assistance options.

How has the timing of these functions changed compared with prior practices Calvaruso: We started asking for financial information at scheduling in January 2011. Before then, our information gathering had been a bit sporadic. We had no one regularly verifying benefits. We started with a new eligibility vendor and changed our internal processes to push eligibility and financial information gathering as far up front as possible. We feel that is the only way we can meet the challenges of the current healthcare environment. This new approach has increased patient satisfaction and reduced denials. Patient satisfaction in our outpatient clinic and hospital has increased 11 percent since early 2011, while our eligibility-related denials have dropped by 20 percent since the middle of 2010.

Persons: We also switched our processes to be more proactive. Before, we verified eligibility and benefits one to two days ahead of patient visits, but we found this to be a patient dissatisfier. It's difficult to tell a patient, "Based on your insurance, the cost will be $5,000, and could you pay that tomorrow or the next day " We find it beneficial to give patients as much information and time to pay as we can.

Koons: To ensure that financial assistance and payment conversations occur early, our organization has established a metric that 85 percent of all scheduled visits are preregistered. Establishing an estimate of patient responsibility up front has many benefits. First, generating a patient estimate is required for point-ofservice collections. Without an estimate, you have no basis from which to collect. The estimate also serves as a communication tool and opens up the financial assistance dialogue. You can set payment expectations for patients, avoid surprises at billing, and allow patients to make payment arrangements.

Blair Baker: Engaging patients three to four days in advance of their visit is key. Organizations should be reaching out to their patients to check insurance, identify payment pathways, and determine financial assistance needs. This occurs because patients are more receptive to these conversations before entering the hospital rather than while waiting to receive care or after care is completed. Giving patients an accurate estimate of their costs before entering the hospital also helps them prepare for their financial obligations. Engaging patients up front in a private and nonpressured setting can set the stage for positive and respectful interactions, while keeping the discussions separate from the care experience.

What challenges do revenue cycle staff face when they do not learn eligibility or patient financial assistance issues up front Koons: If you do not obtain financial information up front, patients can be financially triaged incorrectly and sent down the wrong payment path. For example, if the hospital believes a patient has commercial insurance when the patient is self-pay, the hospital will approach the payment conversation incorrectly. Similarly, if the hospital is unaware that a patient is on Medicare and requires preauthorizations, critical time can be lost. In these situations, there is a serious risk that the hospital will not receive payment. Resolving these situations requires rework on the back end to recontact a patient and resubmit a claim. This is costly, slows down the revenue cycle, and can cause the organization to exceed a payer's timely filing window. Ultimately, the claim can be denied with no possibility of appeal.

Baker: When staff members aren't aware of a patient's financial situation, it also can impact customer satisfaction, because the hospital is playing catch-up and may have to interrupt patient care to have a financial discussion. This can sour patient satisfaction because the patient and family may perceive that the organization puts priority on financial issues over patient care.

Waiting to obtain financial information also puts a hospital behind on some key dependencies before the process gets started. For example, timeframes for preauthorizations and referrals get compressed, which puts the hospital at risk of missing critical windows.

Finally, the ability to collect patient financial obligations decreases the longer you wait within the revenue cycle.

What are challenges in collecting financial information and providing estimates up front Koons: One potential difficulty with patient estimates is that they are just as the name implies - estimates. Although we try to get as close as possible to the actual cost of care based on historical claims, contract information, and the patient's insurance benefits, the patient may require additional services or procedures we aren't anticipating. For example, an additional X-ray may be required or a complication might arise because of a patient's preexisting conditions. The challenge is to communicate that a figure is just an estimate and the bill could be higher than anticipated. If we don't communicate this, it can impact patient satisfaction with the care experience.

Baker: Another challenge that relates to eligibility verification is using consistent eligibility information, including copayments and deductibles. There may be multiple vendors within an organization that supply eligibility information, and insurance company websites provide this information too. Hospitals should determine their source for eligibility information for each payer and use that source consistently across the organization. Collecting disparate information could create mixed messages about the patient's eligibility and financial status.

What role do physician practices play in helping to establish a financial record for patients Baker: Physician practices play a significant role in providing accurate patient information to the hospital, including patient addresses, demographics, and Social Security numbers. If this information is not accurate, the hospital's initial conversation with the patient involves correcting, rather than verifying, information. This can create patient dissatisfaction and a confidence problem for the hospital. If the hospital has to correct basic patient information, the patient might feel the hospital doesn't have its act together from an administrative standpoint and be less likely to believe any financial estimates. Hospitals and physician practices have to share data with each other and ensure that all information is correct and consistent.

Persons: Good physician documentation and coding are also essential. We develop our cost estimates based on the initial codes from the physician's office. Although a patient's bill may be higher than we originally estimated due to unforeseen circumstances, we try to avoid discrepancies that result from inaccurate or insufficient initial coding.

Koons: It is critical that physician practices understand hospital procedures so they can help inform patients about scheduling, registration, and payment. We are on the cusp of further collaboration with our employed physician practices to achieve better communication between acute service lines and physician service lines. More data sharing is definitely something I see in the future.

Persons: We are starting to partner with our physicians to convey a consistent message across service lines. Our physicians are starting to reach out directly to our financial counselors on behalf of patients to get a quick estimate of a procedure, which can assist the patient in making a decision about treatment.

How do you ensure financial responsibility discussions are conducted in a manner that respects the patients and their needs Koons: Our culture of customer focus sets the expectation for respectful communications. We have scripting for scheduling and registration staff, and we offer training that includes role-playing and computer-based modules. We stress in training that hospitalizations are a difficult time for patients and families and it is important to be respectful during all interactions.

Calvaruso: We provide customer service, conflict resolution, and payment negotiation training. In stressing respectful interactions, we shadow staff members to verify that they are communicating appropriately and with a soft touch. We also perform periodic phone observations and are preparing to launch a peer-to-peer blind phone review process in 2013.

Ojeda: We emphasize consistency - this is one of the most important ways to foster respectful interactions. We tell our scheduling and registration staff that they do a disservice to patients if they don't ask for patient financial information, explain patient responsibility, and collect money at the point of service every time. Not doing these tasks consistently can confuse patients. Doing the same task every time sets expectations and ultimately enhances patient satisfaction.

What are some strategies to ensure a positive financial counseling experience (or patients Baker: First and foremost, organizations need to define who will have the financial assistance conversation with the patient. Being a financial counselor requires a specific skill set. Organizations should evaluate their personnel and make sure they have the appropriate staff for the task. If a hospital finds this level of staffing hard to execute, it may want to consider outsourcing the service.

Financial counselors should be experts in the various disability and assistance programs available. They also should leverage technology to streamline the financial assistance conversation and pinpoint the most appropriate approach for the patient. In this age of technology, no one should be flipping through a binder and trying to find the best possible programs. There are software solutions available that assess a patient's financial needs and provide a solution.

Persons: Our financial counselors use a screening tool with 20 questions that guide the counselors to relevant financial assistance options for the patient, such as Medicaid, disability, and workers' compensation. If the patient is not eligible for any of these programs, the financial counselor works with the patient to complete a financial evaluation and application for our charity care program. We call it "community care" because there is less of a stigma for our patients. The term "charity care" can be perceived negatively, so we try to position our assistance program more positively.

Ojeda: It's interesting that more patients are contacting us proactively to ask about their financial responsibility. In the past, the majority of these calls usually came from self-pay patients. Now we are receiving calls from insured patients who want to be prepared and avoid a huge bill. The reality is that patients aren't really examining their healthcare policies until they have to use them. As providers, we are becoming educators for patients about their benefits. As more financial responsibility shifts to patients, the role of educator is becoming increasingly important. We can ensure prompt and complete payment as well as support patients in their overall care experience.

PARTICIPANTS IN THIS HFMA EXECUTIVE ROUNDTABLE Blair Baker is director of product management at Emdeon, Nashville, Tenn.

Stacy Calvaruso is assistant vice president, patient management, at Ochsner Health System, New Orleans.

Joseph Koons, FHFMA, is managing director of revenue cycle at Centra Health, Inc., Lynchburg, Va.

Sue Ojeda is senior manager, patient access and financial counseling, at Tucson Medical Center, Tucson, Ariz.

Maria Persons, CHFP, is director of revenue cycle and HIM at Tucson Medical Center, Tucson, Ariz.

Emdeon is a leading provider of revenue and payment cycle solutions, connecting payers, providers, and patients in the U.S. healthcare system. Our product and service offerings integrate and automate key business and administrative functions of our payer and provider customers throughout the patient encounter. Through the use of our comprehensive suite of products and services, which are designed to easily integrate with existing technology infrastructures, our customers are able to improve efficiency, reduce costs, increase cash flow, and more efficiently manage the complex revenue and payment cycle process.

(c) 2012 Healthcare Financial Management Association

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